NUR 2755 – Multidimensional Care IV (MDC
4) Exam 2 Questions with Answers|
Rasmussen University| Updated| Pass
Guaranteed
1. A client with a traumatic brain injury becomes increasingly difficult to arouse. Which
assessment is the priority?
A. Bowel sounds
B. Airway and breathing
C. Nutritional intake
D. Skin integrity
Correct Answer: B. Airway and breathing
Rationale: A declining level of consciousness can impair airway protection and ventilation. The
nurse should immediately assess airway and breathing while continuing neurological
assessment.
2. Which finding is most concerning in a client with increased intracranial pressure?
A. Mild headache
B. Decreased level of consciousness
C. Mild photophobia
D. Fatigue after activity
Correct Answer: B. Decreased level of consciousness
Rationale: A change in consciousness is an important indicator of neurological deterioration and
possible worsening intracranial pressure.
3. Which position is generally appropriate for a client with increased ICP?
A. Head elevated with neck neutral
B. Flat with the neck flexed
C. Trendelenburg
D. Prone with the head turned
,Correct Answer: A. Head elevated with neck neutral
Rationale: Head elevation and neutral neck alignment promote venous drainage from the brain
and can help limit increases in ICP.
4. Which combination is associated with Cushing response?
A. Hypotension, tachycardia, fever
B. Hypertension with widened pulse pressure, bradycardia, abnormal respirations
C. Hypotension, bradycardia, hypothermia
D. Tachycardia, hypertension, hyperventilation
Correct Answer: B. Hypertension with widened pulse pressure, bradycardia, abnormal
respirations
Rationale: Cushing response is a late and serious sign of increased ICP.
5. A client with head trauma has clear fluid draining from the nose. What should the nurse
suspect?
A. Allergic rhinitis
B. CSF leakage
C. Dehydration
D. Sinusitis
Correct Answer: B. CSF leakage
Rationale: Clear nasal drainage following head trauma may represent cerebrospinal fluid and
requires prompt evaluation.
6. Which finding is characteristic of an epidural hematoma?
A. Gradual symptoms over several months
B. Possible lucid interval followed by deterioration
C. Bilateral leg edema
D. Chronic visual changes
Correct Answer: B. Possible lucid interval followed by deterioration
,Rationale: Epidural bleeding can initially produce loss of consciousness followed by a temporary
lucid period and then rapid neurological deterioration.
7. Which finding is particularly concerning after a head injury?
A. New unequal pupils
B. Normal pupillary response
C. Mild thirst
D. Stable appetite
Correct Answer: A. New unequal pupils
Rationale: New anisocoria can indicate neurological deterioration, mass effect, or impending
herniation.
8. Which intervention is appropriate for a client with suspected cervical spinal injury?
A. Maintain cervical alignment
B. Flex the neck
C. Encourage ambulation
D. Rotate the neck periodically
Correct Answer: A. Maintain cervical alignment
Rationale: Movement of an unstable cervical spine can worsen spinal cord damage.
9. Which finding is consistent with neurogenic shock?
A. Hypertension and tachycardia
B. Hypotension and bradycardia
C. Tachycardia and fever
D. Hypertension and tachypnea
Correct Answer: B. Hypotension and bradycardia
Rationale: Loss of sympathetic tone following high spinal cord injury can cause vasodilation,
hypotension, and bradycardia.
10. Which client is at greatest risk for respiratory failure?
, A. Client with a low lumbar spinal injury
B. Client with a high cervical spinal injury
C. Client with a minor wrist fracture
D. Client with chronic knee arthritis
Correct Answer: B. Client with a high cervical spinal injury
Rationale: High cervical injuries can impair diaphragmatic and accessory respiratory muscle
function.
11. A client with spinal cord injury suddenly develops severe hypertension, headache, and
facial flushing. What should the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Septic shock
D. Hypoglycemia
Correct Answer: B. Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a medical emergency associated with high spinal cord
injuries and is characterized by sudden hypertension and autonomic symptoms.
12. What is the nurse's initial positioning intervention for autonomic dysreflexia?
A. Place the client flat
B. Sit the client upright
C. Place the client prone
D. Use Trendelenburg position
Correct Answer: B. Sit the client upright
Rationale: Sitting upright helps lower blood pressure while the nurse identifies and removes the
triggering stimulus.
13. Which condition commonly triggers autonomic dysreflexia?
A. Bladder distention
B. Mild hunger
4) Exam 2 Questions with Answers|
Rasmussen University| Updated| Pass
Guaranteed
1. A client with a traumatic brain injury becomes increasingly difficult to arouse. Which
assessment is the priority?
A. Bowel sounds
B. Airway and breathing
C. Nutritional intake
D. Skin integrity
Correct Answer: B. Airway and breathing
Rationale: A declining level of consciousness can impair airway protection and ventilation. The
nurse should immediately assess airway and breathing while continuing neurological
assessment.
2. Which finding is most concerning in a client with increased intracranial pressure?
A. Mild headache
B. Decreased level of consciousness
C. Mild photophobia
D. Fatigue after activity
Correct Answer: B. Decreased level of consciousness
Rationale: A change in consciousness is an important indicator of neurological deterioration and
possible worsening intracranial pressure.
3. Which position is generally appropriate for a client with increased ICP?
A. Head elevated with neck neutral
B. Flat with the neck flexed
C. Trendelenburg
D. Prone with the head turned
,Correct Answer: A. Head elevated with neck neutral
Rationale: Head elevation and neutral neck alignment promote venous drainage from the brain
and can help limit increases in ICP.
4. Which combination is associated with Cushing response?
A. Hypotension, tachycardia, fever
B. Hypertension with widened pulse pressure, bradycardia, abnormal respirations
C. Hypotension, bradycardia, hypothermia
D. Tachycardia, hypertension, hyperventilation
Correct Answer: B. Hypertension with widened pulse pressure, bradycardia, abnormal
respirations
Rationale: Cushing response is a late and serious sign of increased ICP.
5. A client with head trauma has clear fluid draining from the nose. What should the nurse
suspect?
A. Allergic rhinitis
B. CSF leakage
C. Dehydration
D. Sinusitis
Correct Answer: B. CSF leakage
Rationale: Clear nasal drainage following head trauma may represent cerebrospinal fluid and
requires prompt evaluation.
6. Which finding is characteristic of an epidural hematoma?
A. Gradual symptoms over several months
B. Possible lucid interval followed by deterioration
C. Bilateral leg edema
D. Chronic visual changes
Correct Answer: B. Possible lucid interval followed by deterioration
,Rationale: Epidural bleeding can initially produce loss of consciousness followed by a temporary
lucid period and then rapid neurological deterioration.
7. Which finding is particularly concerning after a head injury?
A. New unequal pupils
B. Normal pupillary response
C. Mild thirst
D. Stable appetite
Correct Answer: A. New unequal pupils
Rationale: New anisocoria can indicate neurological deterioration, mass effect, or impending
herniation.
8. Which intervention is appropriate for a client with suspected cervical spinal injury?
A. Maintain cervical alignment
B. Flex the neck
C. Encourage ambulation
D. Rotate the neck periodically
Correct Answer: A. Maintain cervical alignment
Rationale: Movement of an unstable cervical spine can worsen spinal cord damage.
9. Which finding is consistent with neurogenic shock?
A. Hypertension and tachycardia
B. Hypotension and bradycardia
C. Tachycardia and fever
D. Hypertension and tachypnea
Correct Answer: B. Hypotension and bradycardia
Rationale: Loss of sympathetic tone following high spinal cord injury can cause vasodilation,
hypotension, and bradycardia.
10. Which client is at greatest risk for respiratory failure?
, A. Client with a low lumbar spinal injury
B. Client with a high cervical spinal injury
C. Client with a minor wrist fracture
D. Client with chronic knee arthritis
Correct Answer: B. Client with a high cervical spinal injury
Rationale: High cervical injuries can impair diaphragmatic and accessory respiratory muscle
function.
11. A client with spinal cord injury suddenly develops severe hypertension, headache, and
facial flushing. What should the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Septic shock
D. Hypoglycemia
Correct Answer: B. Autonomic dysreflexia
Rationale: Autonomic dysreflexia is a medical emergency associated with high spinal cord
injuries and is characterized by sudden hypertension and autonomic symptoms.
12. What is the nurse's initial positioning intervention for autonomic dysreflexia?
A. Place the client flat
B. Sit the client upright
C. Place the client prone
D. Use Trendelenburg position
Correct Answer: B. Sit the client upright
Rationale: Sitting upright helps lower blood pressure while the nurse identifies and removes the
triggering stimulus.
13. Which condition commonly triggers autonomic dysreflexia?
A. Bladder distention
B. Mild hunger
